Choice, trust, and two models of quality

State Efforts to Regulate Provider Networks and Directories: Lessons for the Future

Managed care arrangements are the dominant form of insurance coverage in the United States today. These arrangements rely on a network of contracted providers to deliver services to their enrollees. After the managed care backlash, governments moved to ensure consumer access by issuing a number of requirements for carriers related to the composition and size of their networks and how this information is shared with consumers. The authors provide a comprehensive review of these state-based efforts to regulate provider network adequacy and provider directory accuracy for commercial insurance markets. In addition to common measures of adequacy, they also include requirements specifically targeted to underserved populations. Their assessment comes on the heels of recent empirical work that has raised significant questions about whether these efforts are effective, particularly considering the limited nature of enforcement. They also provide a brief overview and assessment of recent federal government efforts that replicate these state regulations with a focus on lessons learned from state regulations that may help improve their federal counterparts. Furthermore, they outline a future research agenda focused on a more comprehensive evaluation of efforts to ensure consumer access.

Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers

CONTEXT

The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some.

METHODS

The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers.

FINDINGS

The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small.

CONCLUSIONS

While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.

A Knotty Problem: Consumer Access and the Regulation of Provider Networks

In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.

Overlap in HMO physician networks

Health maintenance organizations' (HMOs') restrictions on the size of their physician networks may facilitate cost containment and quality improvement activities but may also impede access to care and impose barriers to those wishing to switch health plans or jobs. We examine the extent, variation, and predictors of overlap in HMO physician networks. We predict that people who switch HMOs have a reasonable likelihood (50 percent) of being able to retain their physician. Overlap ranges from an upper quartile of 69 percent to a lower quartile of 34 percent. Group/staff-model HMOs have little overlap, while younger plans, for-profit plans, and plans in small markets have greater overlap.